Pastoral Counseling Services

Informed Consent Form

I am an Ordained Christian Minister offering pastoral counseling with several years of experience in various counseling settings. I value my relationship with you the client and believe that such relationship is a beacon in the healing process. 

I believe that each individual is unique and has his or her own way of addressing resolutions. Thus, I believe in a wholeness wellness model that helps you the client empower yourself by focusing on what works for you and not in a systematic approach that provides a generic procedure of working on a treatment. Each person's journey is unique.

These pastoral counseling sessions are not to be considered as clinical therapy. I will refer you the client to other clinically licensed therapists should clinical therapy be deemed necessary to accompany your path to wholeness.

Client's Rights

  1. The client may ask questions on what to expect during and end result of the counseling.

  2. The client may decline to proceed the counselling as to the techniques which may be conducted by the counselor.

  3. The client may cease to continue counseling at any time, without any impediment and may return to counseling at any time.

  4. The counselor has the right to dismiss the client from counseling.

  5. The client has the right to review his or her records from the counselor.

  6. Right to confidentiality: Within limits provided for by law, all records and information acquired by the counselor shall be kept strictly confidential in accordance to the principles of a doctor-patient relationship. All information will not be shared or revealed to any person, agency, or organization without the prior written consent of the client.

  7. The client can raise any concerns and to speak with the counselor immediately of any concerns provided that the counselor is likewise available to discuss matters with the client.

·       

Please check the item or items that you believe is affecting you 

 

___Alcohol or drug problems 

___Anger or hostile feelings 

___Anxiety, nervousness, fears 

___Sadness or Depression 

___Eating or appetite problems 

___Family issues 

___Procrastination 

___Physical distress 

___Relationship/marital concerns 

___Sexual concerns 

___Shyness 

___Traumatic experiences 

___Social conflicts 

___Suicidal feelings or behaviors 

___Stress 

___Sleep disorder 

___Self-control 

___Self-esteem or confidence 

___Work or career concerns 

___Other _______________________

 


Payment Policy

All Payments for sessions are due at time of service. Cash, Check, and MC/VISA are accepted. Client is responsible for giving at least 24 hours’ notice for cancellation or client is responsible for the full previously agreed upon session fee. Credit card information will be kept on file and charged in case of a no-show appointment or lack of adequate notice as herein stated for cancellation. Client signature on this Informed Consent form is authorization for all credit card payments according this policy. There will be a $36.00 returned check charge for all returned checks.

 

 

Acknowledgement of Informed Consent Agreement and Privacy Policy

I have reviewed the Pastoral Counseling Informed Consent Agreement and the Notice of Privacy Policy and received a copy of both. I likewise understand my Client's Rights as set forth in these forms. 

I accept this agreement and consent to counseling.

Printed name: ____________________________________

Address: ________________________________________

Address: ________________________________________

City: __________________--- State: _______ Zip: ________

Email __________________________________________

Phone: (       ) ______ - __________

Credit Card Authorization Information:

MC/VISA ______-______-______-______  Exp. Date ___ / ____ (mm/yy)

Name on Card: __________________________________ CSV# _____ (3 digit)

 

Client Signature  ___________________________________  Date ________________ 

Pastoral Counseling Informed Consent Form

Pastoral Counseling Services

I am an Ordained Christian Minister offering pastoral counseling with several years of experience in various counseling settings. I value my relationship with you the client and believe that such relationship is a beacon in the healing process. 

I believe that each individual is unique and has his or her own way of addressing resolutions. Thus, I believe in a wholeness wellness model that helps you the client empower yourself by focusing on what works for you and not in a systematic approach that provides a generic procedure of working on a treatment. Each person's journey is unique.

These pastoral counseling sessions are not to be considered as clinical therapy. I will refer you the client to other clinically licensed therapists should clinical therapy be deemed necessary to accompany your path to wholeness.

Client's Rights

  1. The client may ask questions on what to expect during and end result of the counseling.

  2. The client may decline to proceed the counselling as to the techniques which may be conducted by the counselor.

  3. The client may cease to continue counseling at any time, without any impediment and may return to counseling at any time.

  4. The counselor has the right to dismiss the client from counseling.

  5. The client has the right to review his or her records from the counselor.

  6. Right to confidentiality: Within limits provided for by law, all records and information acquired by the counselor shall be kept strictly confidential in accordance to the principles of a doctor-patient relationship. All information will not be shared or revealed to any person, agency, or organization without the prior written consent of the client.

  7. The client can raise any concerns and to speak with the counselor immediately of any concerns provided that the counselor is likewise available to discuss matters with the client.

·       

Please check the item or items that you believe is affecting you 

 

___Alcohol or drug problems 

___Anger or hostile feelings 

___Anxiety, nervousness, fears 

___Sadness or Depression 

___Eating or appetite problems 

___Family issues 

___Procrastination 

___Physical distress 

___Relationship/marital concerns 

___Sexual concerns 

___Shyness 

___Traumatic experiences 

___Social conflicts 

___Suicidal feelings or behaviors 

___Stress 

___Sleep disorder 

___Self-control 

___Self-esteem or confidence 

___Work or career concerns 

___Other _______________________

 


Payment Policy

All Payments for sessions are due at time of service. Cash, Check, and MC/VISA are accepted. Client is responsible for giving at least 24 hours’ notice for cancellation or client is responsible for the full previously agreed upon session fee. Credit card information will be kept on file and charged in case of a no-show appointment or lack of adequate notice as herein stated for cancellation. Client signature on this Informed Consent form is authorization for all credit card payments according this policy. There will be a $36.00 returned check charge for all returned checks.

 

 

Acknowledgement of Informed Consent Agreement and Privacy Policy

I have reviewed the Pastoral Counseling Informed Consent Agreement and the Notice of Privacy Policy and received a copy of both. I likewise understand my Client's Rights as set forth in these forms. 

I accept this agreement and consent to counseling.

Printed name: ____________________________________

Address: ________________________________________

Address: ________________________________________

City: __________________--- State: _______ Zip: ________

Email __________________________________________

Phone: (       ) ______ - __________

Credit Card Authorization Information:

MC/VISA ______-______-______-______  Exp. Date ___ / ____ (mm/yy)

Name on Card: __________________________________ CSV# _____ (3 digit)

 

Client Signature  ___________________________________  Date ________________ 

Brad Riley Ministries is a 501c3 non-profit organization. Donations are tax deductible.

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